2022 Quality Summit ePosters (Non-CE) - Heart Failure Accreditation-8. Care Transition Team Reduces Heart Failure Readmissions [Honorable Mention #1]

8. Care Transition Team Reduces Heart Failure Readmissions [Honorable Mention #1]

Pdf Summary

Rush University Medical Center implemented a care transition team, known as the REACT team, to reduce readmissions for heart failure patients. The team consisted of a cardiologist, advanced practice providers, a heart failure registered nurse case manager, a pharmacist, and a social worker. They focused on inpatient and post-hospital care, including care transition calls, heart failure education, medication reconciliation, and confirmation of appointments within 7 days. <br /><br />The implementation of the REACT team resulted in a significant decrease in 30-day readmission rates, with the average monthly rate dropping from 24.07% in 2020 to 19.08% in 2021. This reduction in readmissions brings value to patients by reducing their need for hospitalization and improving optimization of treatment for heart failure. It also benefits providers, the healthcare system, and payers by reducing the burden and costs associated with readmissions.<br /><br />The study emphasizes the importance of multidisciplinary care teams and proactive engagement with patients upon admission to identify any issues and support better patient outcomes. It also highlights the need for a system to allocate limited resources to patients with the highest needs.<br /><br />In conclusion, the implementation of the REACT team at Rush University Medical Center has successfully reduced readmissions for heart failure patients and improved the transition from the hospital to home. The study suggests that similar care transitional teams can be invaluable in improving patient care, reducing readmission rates, and optimizing resource allocation.

Keywords

REACT team

readmissions

heart failure patients

care transition calls

medication reconciliation

30-day readmission rates

patient value

multidisciplinary care teams

resource allocation

hospital to home transition